“We have a need for broad-based mental health services. These should be available in every province in Lao PDR. Our core strategy is to enhance the capacity of the existing health workforce to deliver mental health services.”
“Primary care providers can offer mental health support to the community and overcome stigma and discrimination against people with mental disorders, promoting better understanding of these conditions.”
“I believe that we can provide support by going to villages, promoting the importance of mental health, and equipping our people with basic de-stressing skills. And of course, we need to consider the best way to communicate with them during the pandemic by utilizing the skills that we have learned.”
Mental health conditions are worsening as a result of the COVID-19 pandemic. In the People’s Democratic Republic of Lao (Lao PDR), an estimated 75% of people live in rural areas with no access to mental health care services.
The COVID-19 pandemic has exacerbated mental health problems in Lao PDR with a rising number of people suffering from distress; either directly due to illness from COVID-19 or due to the economic hardships they experienced as a result.
Health workers will be trained in providing mental health support to communities nationwide to enable more people to access care at the primary level, and increase understanding to help overcome stigma and discrimination.
WHO is supporting the Government to deliver long-term mental health services at the primary health care level, and to implement tools, guidelines and recommendations on mental health and psychosocial support.
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For Dr Maniphone Vongphathep, a health worker at Hadsayfong district hospital in Vientiane, the capital and largest city of the People’s Democratic Republic of Lao (Lao PDR), mental health is essential to overall health and well-being. She has noticed an increasing trend of distressed and stressed people in the community as a result of the socio-economic impacts of the COVID-19 pandemic.
“I think it is important that we provide mental health care to people in the community. Many people in our community or even worldwide are going through the same difficulties,” she says.
Dr Vongphathep and other staff at the hospital received training from the Department of Hygiene and Health Promotion of the Ministry of Health. The initiative, which aimed to strengthen mental health and psychosocial support skills for people with mental health conditions and community members, was supported by WHO, through the Universal Health Coverage Partnership (UHC Partnership)
“I believe that we can provide support by going to villages, promoting the importance of mental health, and equipping our people with basic de-stressing skills. And of course, we need to consider the best way to communicate with them during the pandemic by utilizing the skills that we have learned,” said Dr Vongphathep.
Lao PDR is among the 115 countries and areas to which the UHC Partnership helps deliver WHO support and technical expertise in advancing universal health coverage (UHC) with a primary health care (PHC) approach. The Partnership is one of WHO’s largest initiatives for international cooperation for UHC and PHC. It is funded by the European Union (EU), the Grand Duchy of Luxembourg, Irish Aid, the Government of Japan, the French Ministry for Europe and Foreign Affairs, the United Kingdom – Foreign, Commonwealth & Development Office, Belgium, Canada and Germany.
Mental health care challenges in Lao PDR
Mental health conditions can be just as serious – and just as deadly – as physical illness. They account for 14% of the total global burden of disease and constitute one of the leading causes of premature death, disability and human misery around the world.
In most countries, there is still a lot of shame and stigma associated with mental health problems. As a result, many people with mental health conditions do not seek help. In addition, such conditions disproportionately affect poor and marginalized people who often have inadequate access to the health system, so again, the true extent of the problem is hidden.
Over the past 10 years, Lao PDR’s health outcomes have improved significantly, but there has been limited progress in the area of mental health. An estimated 210 000 people in the country suffer from a mental, neurological or substance use condition, such as psychosis, epilepsy or substance abuse. Significantly more suffer from the common mental health disorders of depression and anxiety.
Over 95% of people with serious mental illness are untreated, and access to mental health facilities is uneven across the country. It is estimated that 75% of the population of Lao PDR live in rural areas where no mental health services of any kind are available. Only people who live in or near the capital city have access to specialist mental health services. Those in rural areas need to travel to get care, which is often unaffordable.
Out of a total health workforce of just over 13 000 clinical staff, only 42 personnel are working in mental health facilities in the country, providing mental health services to 7 million people. The Government of Lao PDR currently only spends 0.3% of the total health budget on staffing mental health services, despite the country’s high mental health burden.
Primary health care workers have not had previous systemic training in mental health and have had little interaction with mental health services. Psychotropic medications are available, but only a small fraction of the population has free access to them.
Emergencies and mental health
The COVID-19 pandemic has exacerbated mental health problems in Lao PDR with a rising number of people suffering from distress either directly as a consequence of illness from COVID-19 or due to the economic hardships they experienced as a result. The pandemic has also further limited access to mental health care as a result of long lockdowns and some of the specialized institutions in the capital have prioritized treating COVID-19 cases instead.
In Lao PDR, COVID-19 is not the first emergency in recent years. In 2018 the Attapeu dam burst and devastated the district around it. Catastrophic flash flooding affected 13 villages and more widespread flooding expanded across 17 of the 18 provinces in the country. Within a few days, the Government assessed the number of homes and farms destroyed and counted the families who had become homeless. What took longer to emerge was the mental health impact the disaster had inflicted on the survivors of the flood, people who had quite literally seen their life’s work swept away. Death, displacement, loss of homes and livelihoods, shortages of water and food and damage to health facilities all took their toll on the population.
Primary health care and mental health service provision
The Ministry of Health understood that mental health and psychosocial support needed to be a critical part of the recovery plan following the Attapeu dam burst, but also to fulfill a general health need among the population. The Ministry identified primary health care as an ideal platform to improve mental well-being and promotion at village level.
“We have a need for broad-based mental health services. These should be available in every province in Lao PDR. Our core strategy is to enhance the capacity of the existing health workforce to deliver mental health services,” said Dr Bounfeng Phoummalaysith, Minister of Health in Lao PDR.
The Ministry of Health engaged WHO, through the UHC Partnership, for support. WHO’s Mental Health Gap Action Programme (mhGAP) gives countries a practical framework for scaling up mental health services. It is particularly designed for ministries of health in low- and middle-income countries to adapt according to their local contexts and systems for training of health workers.
Based on the mhGAP, WHO supported the development of mental health and psychosocial support guidelines for Lao PDR, which continue to help build national capacity to provide psychosocial support and clinical management across all levels of the health system. At the central level, training took place for staff in 7 central hospitals, 2 of which provide mental health services. In the other 5 hospitals, discussions are shaping the future provision of mental health services. At the provincial level, staff in Attapeu and Savannakhet provincial hospitals were trained and, in the latter, WHO and the provincial health office are exploring ways to strengthen mental health services.
“Primary care providers can offer mental health support to the community and overcome stigma and discrimination against people with mental disorders, promoting better understanding of these conditions,” said Dr Mark Jacobs, WHO Representative to Lao PDR.
The National Mental Health and Psychosocial Support Counselling Guidelines were field tested in Nongsangphai Village, Pak Ngum district, Vientiane, with the village health committee comprising the village chief, village health volunteers and members of mass organizations. In Vientiane, WHO has trained all 9 district health officers to provide the same training to village committees, with support from WHO. More activities are in the pipeline, as part of the collaboration between WHO and the Ministry of Health. This includes training for the village health committees in Attapeu and Savannakhet provinces and the development of an overall action plan on scaling up the initiatives nationwide to reach all communities.
It is important to ensure that mental health and psychosocial support is integrated into the health system, to provide services in communities through a primary health care approach. To implement this, a series of trainings, as well as training of trainers for the guidelines took place at central and sub-national levels, mainly in Attapeu and Savannakhet provinces from late 2020 and early 2021.
Health workers trained in mental health care
- Mental health and psychosocial support training for central trainers: 30 master trainers trained from central hospitals, the Department of Health Care and Rehabilitation, Department of Hygiene and Health Promotion, and community workers from mass organizations including Lao Women’s Union and Lao Youth Union.
- Mental health and psychosocial support sub-national training (Attapeu and Savannakhet provinces): 19 people trained from the Provincial Health Care and Rehabilitation, Health Promotion, Health Education, Lao Women Union, Lao Youth Union, Labor and Social Welfare and Lao Front for National Development.
- COVID-19 mental health and psychosocial support homecare kit training (Vientiane Capital): 60 people trained from the district health office, mainly in the health promotion unit.
- Mental health and psychosocial support hotline joint training with UNFPA (Vientiane Capital): 40 participants trained from Lao Youth Union, Lao Women’s Union, Vientiane Youth Clinic and the National University of Laos.
Mental health and psychosocial support during COVID-19
Following the arrival COVID-19, the Government prioritized providing immediate mental health services during the pandemic. WHO, through its coordinating function, supported the Ministry of Health to convene a high-level consultative meeting with key stakeholders in the health and non-health sectors, and development partners in strengthening mental health and psychosocial support services in Lao PDR.
WHO tools, guidelines and recommendations on mental health and psychosocial support during emergencies were adapted to the local context as information, education and communication materials, and disseminated by the Centre of Information and Education for Health. The materials have been designed for health care workers, people with mental health conditions and their families, people in quarantine including migrants and the public generally. They include messages promoting support for frontline workers, self-care activities for vulnerable groups in dealing with psychological distress during the pandemic and non-discrimination towards frontline workers and people who have recovered from COVID-19.
The Government, with support from WHO, has also developed a standard operating protocol in providing basic de-escalation techniques to manage people in psychological distress. Call operators were also trained to work on a 166/165 national hotline, which has over 200 callers each day.
WHO, through the UHC Partnership, has provided technical support to the Ministry of Health in Lao PDR to train health workers and develop national guidelines that have catalyzed the wider delivery of mental health services across the country. This is expected to significantly strengthen national capacity to provide psychosocial support and clinical management for people living with mental health conditions across all levels of the health system. This means that everyone in the country, including those in rural communities, can have access to mental health care and receive the support they need without stigma and discrimination.